Background: Decision aids help physicians convey information to patients and enable patients to be involved in the decision-making process. There is a lack of use of decision aids in the orthopedic literature. The purpose of this study was to develop a decision board to elicit preferences for treatment of displaced femoral neck fractures in patients over 60 years old.
Materials and Methods: We developed a decision board presenting descriptions and potential outcomes and complications of two treatment options, hemiarthroplasty (HA) and internal fixation (IF), for displaced femoral neck fractures. Five orthopedic surgeons evaluated the face and content validity of the decision board and 10 volunteers completed "scope tests" to determine the comprehensibility. We then presented the decision board to 108 study participants faced with the scenario of sustaining a displaced femoral neck fracture. Participants stated their preference for operative procedure and described the reasons for their choices.
Results: The decision board achieved good face and content validity. All participants in the scope tests appropriately switched their preference to the other modality when probabilities were altered. Most participants found the decision board easy to understand and helpful in making an informed decision. Also, most participants were satisfied with the amount of information presented and with the use of the decision board as a decision making tool. Sixty-one participants (56%) chose IF as their operative procedure of choice quoting less blood loss, shorter operative time, and less invasiveness as the top factors that contributed to this choice. Participants who preferred HA (44%) did so primarily due to the lower re-operation rate.
Conclusions: The decision board is a useful and reliable tool to inform patients about the treatment options for displaced femoral neck fractures. They should be utilized by surgeons to incorporate patients' preferences into the decision-making process.

Background: Minimally invasive (MI) total hip arthroplasty (THA) is an alternative to standard THA, but has created much controversy among orthopedic surgeons. The authors modified the original minimally invasive two-incision THA technique and used large-diameter (32 mm, 36 mm) ceramic-on-ceramic articulation.
Materials and Methods: One hundred and seventy patients that underwent unilateral MI two-incision THA were retrospectively reviewed, and surgical morbidity, functional recovery, radiological properties, and complications were assessed.
Results: Mean Harris hip score (HHS) improved from 41.8 to 96.1 at last followup, and mean Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score from 66.2 to 26.9. The mean lateral opening angle of the acetabular component was 38.2° and the mean stem position was valgus 1.9°. There was an intraoperative femur fracture and one revision surgery due to stem subsidence. No patient had dislocation.
Conclusions: Our data suggest that this modified technique combined with large ceramic femoral head is safe and reproducible in terms of achieving proper implant positioning and early functional recovery.

Background: There are a few studies reporting the long term outcome of conservatively treated acetabular fractures. The present study aims to evaluate the quality of reduction, and radiological and functional outcome in displaced acetabular fractures treated conservatively.
Materials and Methods: Sixty-nine patients (55 men and 14 women) with 71 displaced acetabular fractures (mean age 38.6 years) managed conservatively were retrospectively evaluated. There were 11 posterior wall, 5 posterior column, 6 anterior column, 13 transverse, 2 posterior column with posterior wall, 9 transverse with posterior wall, 6 T-shaped, 1 anterior column with posterior hemi-transverse, and 18 both-column fractures. The follow-up radiographs were graded according to the criteria developed by Matta J. Functional outcome was assessed using Harris hip score and Merle d'Aubigne and Postel score at final followup. Average follow-up was 4.34 years (range 2-11 years).
Results: Patients with congruent reduction (n=45) had good or excellent functional outcome. Radiologic outcome in incongruent reduction (n=26) was good or excellent in 6 and fair or poor in 20 hips. The functional outcome in patients with incongruent reduction was good or excellent in 16 and satisfactory or poor in 10 hips. Good to excellent radiologic and functional outcome was achieved in all patients with posterior wall fractures including four having more than 50% of broken wall. Good to excellent functional outcome was observed in 88.8% of both-column fractures with secondary congruence despite medial subluxation.
Conclusions: Nonoperative treatment of acetabular fractures can give good radiological and functional outcome in congruent reduction. Posterior wall fractures with a congruous joint without subluxation on computed tomography axial section, posterior column, anterior column, infratectal transverse or T-shaped, and both-column fractures may be managed conservatively. Small osteochondral fragments in the cotyloid fossa or non-weight-bearing part of the hip with a congruous joint do not seem to adversely affect the functional outcome. Displaced transverse fractures with "V" sign may require operative treatment.

Background: The standard commercially available marketed prostheses sometimes may not be the best fit to Indian patients because of the large anatomic variation. Orthopedic surgeons always stress the need for a proper implant-patient match in hip joint replacements, in particular, for a cementless femoral stem. The complications of mismatch are aseptic loosening, improper load distribution, and discomfort. The present study was undertaken to compare the differences in dimensions between femurs of elderly Indians and those of populations from other regions in order to solve the problem of a possible geometric mismatch between a selected implant and the hip joint as far as Indian patients are concerned.
Materials and Methods: Measurements were made using computer aided design techniques on computed tomography (CT) scanned images of 98 femurs (56 left and 42 right). The software used to convert the CT images into solid models was MIMICS® (Materialize, Inc., Leuven, Belgium). The geometrical parameters, viz., the femoral head offset, femoral head center (HC), femoral head diameter, femoral head relative position, position of shaft isthmus, neck-shaft angle, bow angle, femoral neck length, canal flare index, femoral length, and canal width at various locations, were chosen to design best-fit standard femoral stems for cementless insertion. These data were compared with the published data of other countries.
Results: A difference of 16.8% was found in the femoral head offset between Indian and Swiss populations, which can affect soft tissue tension and range of motion. At a distance of 20 mm above the lesser trochanter (LT), the anteroposterior (AP) canal width was found to differ by 45.4%, when compared with a French population which can affect the mechanical stability of femoral stem. Femoral dimensions of Indian male and female subjects have also been compared and differences evaluated. At the LT, the aspect ratio (ratio of mediolateral canal width and AP canal width) in case of males (1.198) is approximately13% higher than that of females (1.059).
Conclusions: This study indicates a need for redesign of femoral stems. The obtained anthropometric femoral dimensions can be used to design and develop indigenous hip joint prosthesis in India. The results of this study can also be used in forensic anthropometric studies.

Pseudarthrosis of the surgical neck of humerus treated by buttressing with a medial cortico-cancellous graft

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J Maheshwari, Vinay K PandeyDOI:10.4103/0019-5413.91635 PMID:22345807

Background: Pseudarthrosis of surgical neck of humerus is uncommon condition. Different methods of improving the stability of fixation have been described, including impaling the shaft into the head, placing a tension suture through the rotator cuff, or using an intramedullary cortical graft. We report our results of cortico-cancellous strut graft medially to counter the varus force, in conjunction with a fixed-angle implant on the lateral side.
Materials and Methods: We used this technique in seven cases of pseudarthrosis of surgical neck of the humerus. There were four women and three men, ranging in age from 22 to 65 years. All were treated with a tricortical medial buttress bone graft and fixed-angle fixation device on the lateral side. A locking proximal humerus plate (Synthes) was used in six cases, and a bent reconstruction plate (Synthes) was applied in one case. The one in which reconstruction plate was applied was operated before the advent of locking plates. The limb was immobilized in 30° of abduction over a cushion for 6 weeks, followed by a sling for another 6 weeks.
Results: The followup varied from 18 to 96 months. All our cases healed within mean 5.1 months (range 4-6 months). There was one case of avascular necrosis. All cases had useful function of shoulder.
Conclusion: The medial buttressing by strut graft with external fixation by laterally placed fixed angle plate is successful to achieve fracture union in pseudarthrosis of surgical neck of humerus.

Background: Nonunion of humeral shaft fractures after previously failed surgical treatment presents a challenging therapeutic problem especially in the presence of osteoporosis, bone defect, and joint stiffness. It would be beneficial to combine the use of external fixation technique and intramedullary rod in the treatment of such cases. The present study evaluates the results of using external fixator augmented by intramedullary rod and autogenous iliac crest bone grafting (ICBG) for the treatment of humerus shaft nonunion following previously failed surgical treatment.
Materials and Methods: Eighteen patients with atrophic nonunion of the humeral shaft following previous implant surgery with no active infection were included in the present study. The procedure included exploration of the nonunion, insertion of intramedullary rod (IM rod), autogenous ICBG and application of external fixator for compression. Ilizarov fixator was used in eight cases and monolateral fixator in ten cases. The monolateral fixator was preferred for females and obese patients to avoid abutment against the breast or chest wall following the use of Ilizarov fixator. The fixator was removed after clinical and radiological healing of the nonunion, but the IM rod was left indefinitely. The evaluation of results included both bone results (union rate, angular deformity and limb shortening) and functional outcome using the University of California, Los Angeles (UCLA) rating scale.
Results: The mean follow-up was 35 months (range 24 to 52 months). Bone union was obtained in all cases. The functional outcome was satisfactory in 15 cases (83%) and unsatisfactory in 3 cases (17%) due to joint stiffness. The time to bone healing averaged 4.2 months (range 3 to 7 months). The external fixator time averaged 4.5 months (range 3.2 to 8 months). Superficial pin tract infection occurred in 39% (28/72) of the pins. No cases of nerve palsy, refracture, or deep infection were encountered.
Conclusion: The proposed technique is effective in treating humeral nonunion especially in the presence of osteoporosis and short bone segments. The inclusion of intramedullary rod as internal splint improves stability of fixation and prevents refracture after fixator removal.

Background: The failure of the conventional nailing of both forearm bones or isolated fractures of radius and ulna pose a potential problem of nail migration and rotational instability, despite the best reduction. The purpose of this paper is to evaluate the results of screw elastic intramedullary nail for the treatment of adult diaphyseal fractures of both forearm bones, which effectively addresses the problems associated with the conventional nailing systems for the forearm fractures.
Materials and Methods: Seventy-six adults with forearm fractures (radius and ulna or isolated fracture of the single bone) were retrospectively evaluated. Fifty males and 26 females with the mean age of 38 years (range, 18-70 years) underwent closed reduction and screw intramedullary nail fixation. Ten patients required limited open reduction. The fractures were classified according to the AO/OTA system. The average followup was 12 months (range, 6 to 18 months).
Results: The mean surgical time was 45 minutes (35 to 65 minutes). The meantime to union was 14 weeks (10-21 weeks). The results were graded as excellent in 50, good in 18 patients, and acceptable in eight patients, using the criteria of Grace and Eversman. We had superficial infection in three cases, one case of delayed infection, painful bursa in two cases, delayed union in two cases, malunion with dislocation of the DRUJ in two cases, injury to the extensor tendon of the thumb in one case, and one case of incomplete radioulnar synostosis.
Conclusion: Closed reduction and internal fixation of forearm fractures by screw intramedullary nails reestablishes the near normal relationship of the fractured fragments. Screw intramedullary nail effectively controls both rotatory forces and the migration of the nail. It produces excellent clinical results in isolated fractures of either bones, as well as both bones of the forearm in adults.

Background: A number of techniques have been described to reattach the torn distal biceps tendon to the bicipital tuberosity. We report a retrospective analysis of single incision technique using an endobutton fixation in sports persons.
Materials and Methods: The present series include nine torn distal biceps tendons in eight patients, fixed anatomically to the radial tuberosity with an endobutton by using a single incision surgical technique; seven patients had suffered the injuries during contact sports. The passage of the endobutton was facilitated by using a blunt tipped pin in order to avoid injury to the posterior interosseous nerve. The patients were evaluated by Disabilities of the Arm, Shoulder and Hand (DASH) score and Mayo elbow score.
Results: The average age of the patients was 27.35 years (range 21-42 years). Average follow-up was 41.5 months (range 24-102 months). The final average flexion extension arc was 0°-143°, while the average pronation and supination angles were 77° (range 70°-82°) and 81° (range 78°-85°), respectively at the last followup. All the patients had a Disabilities of the Arm, Shoulder and Hand (DASH) score of 0 and a Mayo elbow score of 100 each. All the seven active sports persons were able to get back to their respective game. There was no nerve injury or any other complication.
Conclusions: The surgical procedure used by us is a simple, safe and reproducible technique giving minimal morbidity and better cosmetic results.

Context: Congenital heart disease (CHD) patients bear a higher risk of scoliosis during their lifetime compared to their normal counterparts. On the other hand, operation on chest wall has been shown to increase the risk of scoliosis. However, the data are inconclusive. The present retrospective analysis is undertaken to determine the frequency of post-thoracotomy/sternotomy scoliosis in children with CHD.
Materials andMethods: One hundred and eighty children with CHD who underwent thoracotomy/sternotomy and had a minimum followup of 3 years in a teaching center from 1997 to 2010 were recruited. After operation, all the patients were regularly examined for the development of scoliosis. 102 patients underwent thoracotomy and 78 sternotomy. Student's t test, Chi-square test, Fisher's exact test were used for statistical analyses.
Results: Eighty-eight males and 92 females with a mean age of 9.95 ± 2.31 (range: 5-15) years were enrolled. The mean age at operation was 2.59 ± 1.66 (range: 0-9) years and the mean follow-up period was 7.36 ± 2.12 (range: 5-13) years. Scoliosis was confirmed in two patients (1.1%): 1 (1%) in the thoracotomy group (a 12-year-old female operated 2 years earlier with a spinal 22 o convexity to the right and 78 o kyphosis) and another (1.1%) in the sternotomy group (an 8-year-old female operated during her neonatal period with a spinal 23 o convexity to the left).
Conclusion: Scoliosis is not a common finding among the operated children with CHD in our center.

Background: Posterior endoscopic discectomy is an established method for treatment of lumbar disc herniation. Many studies have not been reported in literature for lumbar discectomy by Destandau Endospine System. We report a series of 300 patients operated for lumbar dissectomy by Destandau Endospine system.
Materials and Methods: A total of 300 patients suffering from lumbar disc herniations were operated between January 2002 and December 2008. All patients were operated as day care procedure. Technique comprised localization of symptomatic level followed by insertion of an endospine system devise through a 15 mm skin and fascial incision. Endoscopic discectomy is then carried out by conventional micro disc surgery instruments by minimal invasive route. The results were evaluated by Macnab's criteria after a minimum followup of 12 months and maximum up to 24 months.
Results: Based on modified Macnab's criteria, 90% patients had excellent to good, 8% had fair, and 2% had poor results. The complications observed were discitis and dural tear in five patients each and nerve root injury in two patients. 90% patients were able to return to light and sedentary work with an average delay of 3 weeks and normal physical activities after 2 months.
Conclusion: Edoscopic discectomy provides a safe and minimal access corridor for lumbar discectomy. The technique also allows early postoperative mobilization and faster return to work.

Background: C1 lateral mass-C2 transpedicular fixation is an accepted surgical procedure of choice in a large number of cases with traumatic atlanto-axial instability. However, bony and vascular anomalies can predispose to unacceptably high risk with this procedure, And hence are the contraindications for this procedure. The purpose of this study is to analyze the clinical and radiological results in such cases for which only unilateral fixation has been performed in cases where bilateral fixation could not be performed due to various reasons.
Materials and Methods: Eight patients (7 males, 1 female) with a mean age of 41.12 years (range 12-68 years), who presented with traumatic atlanto-axial instability and in whom bilateral fixation could not be performed, were treated with unilateral C1 lateral mass-C2 transpedicular fixation. Of these cases, preoperative vertebral artery occlusion was noted in one case, iatrogenic vertebral artery injury in two cases and bony anomalies or fractures in the remaining of five cases. All patients were evaluated clinically with the American Spinal Injury Association (ASIA) scale and radiologically with computed tomography scans and serial X-ray using criteria to evaluate stability.
Results: All cases were evaluated at 6 months followup with mean followup of 2 years and one month (range 6 months to 4 years). All eight patients showed adequate stability and fusion at 6 months; clinically there was no significant restriction of neck movement in any of the patient. There was no neurological deterioration in any of the patient at their last follow-up.
Conclusion: Unilateral C1 lateral mass-C2 transpedicular fixation could be considered a viable option in cases of traumatic atlanto-axial instability where vascular and osseous anomalies contradict a bilateral fixation.

Background: The optimal approach to provide satisfactory decompression and minimize complications for ossification of the posterior longitudinal ligament (OPLL) involving multiple levels (3 levels or more) remains controversial. The purpose of this study was to compare the results of two surgical approaches for cervical OPLL involving multiple levels; anterior direct decompression and fixation, and posterior indirect decompression and fixation. We present a retrospective review of 56 cases followed at a single Institution.
Materials and Methods: We compared patients of multiple levels cervical OPLL that were treated at a single institution either with anterior direct decompression and fixation or with posterior indirect decompression and fixation. The clinical records of the patients with a minimum duration of follow-up of 2 years were reviewed. The associated complications were recorded.
Results: Fifty-six patients constitute the clinical material. 26 cases were treated by anterior corpectomy and fixation and 30 cases received posterior laminectomy and fixation. The two populations were similar. It was found that both anterior and posterior decompression and fixation can achieve satisfactory outcomes, and posterior surgery was accomplished in a shorter period of time with lesser blood loss. Although patients had comparable preoperative Japanese Orthopaedics Association (JOA) scores, those with a canal occupancy by OPLL more than 50% and managed anteriorly had better outcomes. However, for those with more severe stenosis, anterior approach was more difficult and associated with higher risks and complications. Despite its limitations in patients with high occupancy OPLLs, through the multiple level laminectomy, posterior fixation can achieve effective decompression, maintaining or restoring stability of the cervical spine, and thereby improving neural outcome and preventing the progression of OPLL.
Conclusions: The posterior indirect decompression and fixation has now been adopted as the primary treatment for cervical OPLL involving multiple levels with the canal occupancy by OPLL <50% at our institution because this approach leads to significantly less implant failures. Those patients with the occupancy ≥50% managed with anterior approach surgeries had better outcomes, but approach was more difficult and associated with higher risk and complications.

Trapezium fractures account for <5% of all carpal fractures. Of these about 20% are vertical sagittal fractures of the body of trapezium and are classified as type IV. We report a case of coronal fracture of the trapezium, which was treated by open reduction and internal fixation with Kirschner wires and ligamentotaxis by external fixator. This fracture pattern has not been reported before.

Osteoid osteomas are small-sized benign painful bony tumors. The authors report the case of an osteoid osteoma located in the distal third of the tibia, treated by the surgical excision of the nidus using the intraoperatively isotopic marking which allows reducing the incision size and the bony resection.

Incidence of perioperative visual loss ranges from 0.06% to 0.2% with the most common cause as ischemic optic neuropathy. We report one-year follow up of a 50-years-old hypertensive housewife who underwent lumbar decompression and fusion for degenerative scoliosis, but woke up with painless unilateral visual loss. Fundus examination was normal. Her visual acuity improved from initial finger counting close to face to finger counting at 3 m at 1 year. Identification of high risk patients may help in appropriate preoperative counselling, prevention and early recognition of this devastating complication.

Broken implants, especially broken wires at difficult sites, may pose a challenge for the treating orthopedic surgeon. We describe a method for extraction of a broken guidewire that was, protruding into the hip joint following the insertion of a proximal femoral nail. A 35-year-old man with displaced femoral neck fracture with ipsilateral fracture shaft of femur was operated and fixed with long proximal femoral nail. The guidewire of proximal screw broke during the process of drilling. The tip of the 2-cm-long broken guidewire was touching the articular surface. The guidewire was misdirected posteroinferiorly from its path for the insertion of the proximal screw (6.8 mm), this screw was removed and bone endoscopy was performed with a 30° arthroscope. The broken end of the guidewire was located under direct vision. The grasper was introduced with its jaws at the 8 O'clock position and its position was confirmed under a C-arm image intensifier in both anteroposterior and lateral views. The broken end of the guidewire was grasped and it was retrieved. The screw was replaced in its original track to complete the procedure. The fractures united and patient was asymptomatic when last followed-up at 12 months.